Inspection on 15/01/09 for Salisbury Road

This inspection was carried out on 15th January 2009.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Salisbury Road 15/01/08

Salisbury Road 10/10/06

Salisbury Road 25/02/06

Salisbury Road 07/02/05

Salisbury Road 25/11/04

Salisbury Road 22/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Salisbury Road 22-23 Salisbury Road Leyton London E10 5RG     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Pursotamraj Hirekar     Date: 1 5 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Salisbury Road 22-23 Salisbury Road Leyton London E10 5RG 02085568147 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): l.walker@mcch.co.uk MCCH Society Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 7 Number of places (if applicable): Under 65 Over 65 0 learning disability Additional conditions: 7 The maximum number of service users who can be accommodated is: 7 The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD Date of last inspection Brief description of the care home 23 Salisbury Road is registered to provide personal care and support for up to seven residents of either sex. The home is operated by MCCH. The home is located in a residential area of Leyton, North East London. It is close to shops, community facilities and is well served by public transport. All of the people that live in the home have complex needs and require a high level of support and supervision. Residents are encouraged to maintain family relationships and some have regular visits home, including for overnight/ weekend stays. Care Homes for Adults (18-65 years) Page 4 of 30 Care Homes for Adults (18-65 years) Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This is the report of the unannounced key inspection carried out on the 15/01/09 over 5 hours 55 minutes by Pursotamraj Hirekar. The manager coordinated the inspection. The method of inspection included study of care plans, risk assessments, staff records, relevant care delivery documents, medication reconciliation, partial tour of the premises, discussion with staff and manager, observation and conversation with people living at the home. The pre-inspection survey of people who use this service, staff responses, the annual quality assurance assessment (AQAA) - providers self assessment and in response to key inspection headline feedback session the documentation received from the manager, post this inspection is included for analysis and preparation of this report as Care Homes for Adults (18-65 years) Page 6 of 30 well. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the care home does well: What has improved since the last inspection? What they could do better: The home should produce the statement of purpose in a pictorial format. The home should complete signing the terms and conditions for each individual service user detailing the service provision, rights and responsibilities and fees as well. The home must complete person centred plans for each individual service user. The home must carry out 6 monthly reviews regularly and reflect changes in the care plan for each individual service user. The home must develop weekly activity planner for each individual service user taking into account their strengths, needs and risk. The home should obtain medication consent from the service users or their representative as appropriate. The home must review all the recommendations from the fire risk assessment and conclude implementation on schedule. The home must complete all the repair, replacement and redecoration work of the individual and communal areas on schedule. The home must make available all the appropriate evidence with regard to recruitment checks of bank staff. The home should separate current working documents from the old documents and file or archive them as appropriate. Care Homes for Adults (18-65 years) Page 8 of 30 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has made appropriate arrangements for potential people who use the service to make an informed decision that, the home can meet their needs. Evidence: The statement of purpose and the service user guide were comprehensive that contained information about the service provision and the details of service arrangements presented in a pictorial format as well. However, the statement of purpose could also be produced in a pictorial format as well. There has been no new admission since the previous inspection in January 2008. All the service users currently living at the home for many years. The policies and procedures regarding pre - admission assessment, to make an informed judgement on the suitability of the potential service user, taking into account the needs of the service user and capacity of the staff working at the home to demonstrate that the home could meet the assessed needs, were examined during the previous inspection. Staff was observed communicating with people using the service in different forms of Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: communication to suit their individual preferences and needs. The contract/terms and conditions examined did not include the fee details and were not signed. This was brought to the attention of the manager, who confirmed with us in writing post this inspection that, terms and conditions for each individual service user shall be completed by 26/02/09. Information received from the manager prior to this inspection stated that the home had clear procedures for prospective users through a local nomination and allocations panel which will look at the referral to ensure that the service is right for the person, they will make their recommendation and this will be fed by all involved. Care Homes for Adults (18-65 years) Page 12 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home had developed assessments and support plans that were reviewed and updated regularly to reflect the changing needs of the service users. However, further work was needed to prepare person centred plans and carry out 6 monthly reviews for each individual service user. Evidence: The care documents of 3 people using the service were seen which included general profile, assessment of need, identified goals, strength and needs, risk assessments, primary care guidelines, staff guidelines, and one persons person centred plan and for the remaining service users, the person centred plans work was in progress. The information for one person was holistic and from the view of the people using the service in relation to their goals, needs and strengths. The plans had been written in sufficient detail and need to detail for all the goals identified, to ensure that anyone working at the home could provide the necessary care. The information was written to help staff to provide the right level of support in relation to promoting independence Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: and skills for daily living such as personal care, domestic tasks and accessing the community. In response to the inspection headline feedback session, the manager has written to us post this inspection that the person centred plans have been completed for one person and have started for another person and for the remaining service users the person centred plans should have started by September 2009. There were some old documentations from the year 2004 onward on the individual service user file along with the current care documents. It would be appropriate to keep only the current care documentation on the individual service user file to avoid any potential confusion whilst providing care. The old documentation could be filed separately or archived as appropriate. The support plans were reviewed and regularly updated, as and when the need arouse and the changes are reflected in the support plan. For example on eating and drinking, hygiene and dressing, travelling and behaviour guidelines. The staff working were aware of the changes to the support plans of the people using the service. However, this is not the case for all the service users, which need to be carried out. This was brought to the attention of the manager during the inspection headline feedback session, the manager has written to us post this inspection that six monthly review process for all the service user would start from 01/02/09. The people using the service can access social and community activities locally, which include their daily routines; going to their place of work or day centre. observations made indicated that the relationship between people using the services and the staff was relaxed, friendly and polite, showing respect to each other when they are talking or expressing a view. The staff on duty said people make their own decisions or are supported through conversation to make their own decision. For example, member of staff provided support to people whilst shopping, preparing lunch, laying and clearing the dinning table. Information received from the manager prior to this inspection stated that each service user has a key worker, to ensure that they are provided with amount of support they require on, a one to one basis. Also, the home plans to make improvements in the next 12 months as, to continue and encourage the development of the staff, so that they will be in the position to initiate good working practise. Care Homes for Adults (18-65 years) Page 14 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service experience and appeared to be enjoying a lifestyle that suits them, being part of the community and having meals of their choice. However, further improvements was needed to match the strengths, needs and associated risks of each individual service user. Evidence: Information about individual daily, social and community activities are detailed in the weekly planner. Staff said people are supported to continue participating in daily social and community activities. The people using the services, confirmed during the discussion that they continued to participate in daily activities ranging from the day services, going out socially with family. People can choose how to spend the evening and weekends, ranging from seeing family and watching television. The weekly planner presented for individual service user reflected in the daily activities of the Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: people using the service. However, further work was required to reflect daily activities in relations to the identified strengths and needs for each individual service user. This was brought to the attention of the manager during the inspection headline feed back session. The manager has written to us, post this inspection that weekly planners will be devised in line with strengths and needs analysis, goals, and risk assessments. These will all form part of the weekly planner, which will be more opportunity based and the process will commence from 02/02/09. The people who use the service indicated that they felt in control of their life at home and were not restricted in what they did. There was evidence that the home supported people to maintain family links and friendships inside and outside the home, in accordance with their wishes. People who were spoken with, confirmed this view. Staff demonstrated a good understanding of the people they work with, recognising if the person is anxious or unhappy, and how to approach them. People who use the service spoken to have said that they have the freedom to make choice of the meals and mealtime. Staff said they always encourage the people to choose the meals. It was noted that the people were neatly dressed and that they were treated as individuals. Throughout the inspection staff were seen talking to people and treating them with dignity; the people using the service had a good rapport with staff and the relationship between staff and the people appeared to be that of encouragement and supportive. Information received from the manager prior to this inspection stated that community access has improved, they are going out more on leisure activities and found new courses for services users accessing college. Care Homes for Adults (18-65 years) Page 16 of 30 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The personal and health care needs of people, who use the service are met promoting their independence and quality of life. Evidence: The personal and health care needs of the people who use the service are detailed in their individual and support plans, which were clearly presented, staff has guidance in relation to the level of support required, if any. Risk assessments are detailed and to include information about personal care, personal hygiene, medication and day care activities. Staff appeared to have good working relationship with the people who use the service. This was supported through the observations made during the interactions, the people said; they are happy living at the home. Records viewed suggested that people received personal support in the way they preferred and were encouraged to maximise their independence. The people were able to identify the staff with their name, and said they were happy with the support they receive from them. The people who use the service appeared to not have restrictions to continue living their lifestyle of their choosing. The home had made arrangements for the people to Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: maintain contact with family and friends. The people who live at the home their privacy and dignity is respected. Support plans detailed emergency contacts and health care professionals involvement in their care. The records showed people had regular appointments with health care professionals. Trained staff administer medication, staff training records, and staff spoken to have confirmed this. The staff on duty demonstrated a good understanding of the administration of medication, and the importance of having medication on time. Medication reconciliation was carried out for 3 service users and found that the home has been following appropriate procedures for receipt, storage, administration, MAR charts and return. The home has also further introduced an additional MAR chart for the witness to sign on administration of medication. However, the home need to obtain medication consent from the service user or their representatives. This was brought to the attention of the manager during the inspection headline feedback session, the manager has written to us, post this inspection that with immediate effect parents of the service users will be asked to sign the medication consent form. Information received from the manager prior to this inspection stated that the home had detailed personal and health care support plans for all the people who use the service and their health care professional appointments records are maintained as appropriate. Staff have attended training delivered by National Autistic Society and planned to put the learning in day to day practise. Care Homes for Adults (18-65 years) Page 18 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service their interests are protected by complaints procedures and practises. Evidence: The complaints policy and procedure was available at the home. The people using the services appeared to know that they were aware whom to complaint or express concerns about the provision of care provided to them. If a person is not happy, they normally speak with their key worker or the manager. The home had maintained a record of incidents and accidents. This was further supported from the documentation that was made available during the inspection and the details recorded thereof. We have not received any concerns, complaints, or allegations about the home, except for one notification under regulation 37 about a staff member and a service user. This has been appropriately referred to the safeguarding team and the police, the manager of the home has cooperated with the investigating agencies and has updated us with the progress of the referral. The staff member has been suspended from duties pending outcome of investigations, the menager informed us. The home had arranged for staff training on safeguarding, the staff on duty, demonstrated an adequate awareness of their role, responsibility, and procedures they Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: are required to follow in relation to any allegation or suspicion of abuse. Staff were confident to whistle-blow poor or bad practise and confirmed that the manager is available should any concerns arise. The people who use the service can choose to manage their own money if they are able to do so. Records of money transaction were maintained. The manager described the process for recording and handling of money for people, which appeared adequate. On a sample, money transaction records and the balances for 3 people were checked and found in order. Information received from the manager prior to this inspection stated that the home had clear complaints policy and procedures, and planned to re-instate the family group meetings so that any concerns can be raised at the stage where it can be dealt at lower level. Care Homes for Adults (18-65 years) Page 20 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service live in clean and homely environment. However, further development work that was in progress needed to be completed as scheduled. Evidence: The home was maintained clean and tidy without any offencive odours. The home has had a regular premises maintenance programme in place. As part of premises maintenance programme, repair and redecoration work has been carried out in the individual and communal areas of the building, during the inspection kitchen work was being undertaken. The manager informed us in writing post this inspection that the new kitchen work is scheduled for completion by end of January 2009, bedroom furniture has been ordered and awaiting delivery, redecoration work in the hall, lounge, stairs and landing, new carpets and new furniture should be in place by end of April 2009. The people appeared to be at ease in the home with the staff on duty, choosing to sit in the lounge or going to their bedroom. The hot water temperature checks for bath, shower and wash basins were regularly Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: carried out. One of the service user bedroom radiator was not working and has come out of the wall. The manager was aware of this problem and has written to us post this inspection that the contractors visited on the 16/01/09 to resolve and the housing officer had meeting with housing association on the 19/01/09 toward a resolution of this recurring problem. In response to the fire and community safety directorate letter, the internal fire officer has carried out risk assessment of the home in September 2008 and made some recommendations for improvements. Some of these have been implemented, for example fire alarm linked to fire brigade, staff training has been booked for 11/02/09, however the manager must review all the recommendations and conclude implementation as scheduled. Care Homes for Adults (18-65 years) Page 22 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service are protected by staff recruitment procedures, training and supervision. However, further development was needed to evidence bank staff records. Evidence: The interaction of staff with the people using the service was good; there was good rapport, both verbal and non-verbal communication was used. The staff appeared to be aware of the needs of the people and their daily routines and how best to communicate with them. On a random sample, 3 staff recruitment records were seen and the manager informed us that all the staff records were at the head quarters and this was in agreement with us. The manager had further informed us that, staff appointed upon receipt of application, interview, satisfactory references, POVA and Criminal Records Bureau (CRB) check. However, for the staff whose CRB was over 3 years old, the manager was coordinating with the human resources department of the company for their renewal, as a best practise initiative. This was further confirmed in writing with us, post this inspection. Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: Staff training records showed that staffs have received training in safeguarding, medication, manual handling, first aid, food hygiene and NVQ level 2 and 3 and fire safety training is scheduled for February 2009. This was supported by staff spoken to, which identified varied training, which they had undertaken. The home was also in the process of completing annual appraisals alongside staff training needs analysis, to help plan staff training for the coming year, the manager informed us. The home had maintained adequate staff deployment ratio with the help of bank staff as and when necessary. The manager mentioned that she was coordinating with the human resources department to keep necessary information about bank staff at the home. Staff on duty confirmed they received regular supervision. This was further confirmed with the staff supervision record maintained at the home, for the bank staff as well. Information received from the manager prior to this inspection stated that the home had ensued appropriate staff deployment to meet the needs of the people who use the service and staff are given relevant training and supervision to wards this end as well. Care Homes for Adults (18-65 years) Page 24 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager and the staff work as team, and have good working relationship with the people who use the service and with those external professionals who provide services to meet the needs of the people living at the home. Evidence: The home do not have a registered manager. The home is being managed by a new manager since April 2008 and the registered managers application work was in progress. The manager has said that she has over 15 years of work experience with learning disability and mental health service users, she has NVQ4 in care, diploma in management studies and completed registered manager award. Discussion with the staff on duty and the people who live at the home, the manager appeared to have developed good working relations with the people who use the service and the staff as well. The various care documents seen on this inspection confirmed that the staff have clear roles and responsibilities in relation to the management of the home. Staff appeared to Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: get involved to discuss any concerns, areas of improvements and staff development as well, that are in the best interest of the people who use the service. As part of the quality assurance system and procedure the home had a monthly quality monitoring visits in place and continuous improvement plan produced. Service users meeting are held on a weekly basis to ensure that the people living at the home their quality of life goals both short term and long term, were reviewed and appropriate efforts were made to achieve them. The manager informed us that she was planning to undertake service users survey every 6 months starting February 2009 and also convene a parents meeting on completion of the kitchen and dinning room work and then follow up at regular intervals as per the choice of the service users parents. It is anticipated that these meetings should be beneficial to meet the assessed goals of the service users. The premises, health and safety checks and risk assessments were carried out and these checks help in identifying any concerns to the premises and to action them on time, please refer environment outcome group of this report for more information. The staff spoken to have said that the people living at home are encouraged to express themselves about running of the home, what improvements are made in relation to their accommodation, decor and they can speak with the staff at any time. Information received from the manager prior to this inspection stated that the home has weekly meetings with the service users, as part of health and safety walking routes, fire testing and water temperatures are checked weekly and appropriate certification for gas and electric and PAT is also undertaken. Care Homes for Adults (18-65 years) Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 6 17 The Registered Person must ensure that all records are reviewed regularly and are up to date. The work is in progress. 29/05/2008 Care Homes for Adults (18-65 years) Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 6 15 The home must complete person centred plans for each individual service user. All service users do not have person centred plans 30/04/2009 2 6 15 The home must carry out 6 monthly reviews regularly and reflect changes in the care plan for each individual service user. Each individual service user care plan are not reviewed 6 monthly. 27/02/2009 3 14 16 The home must develop weekly activity planner for each individual service user taking into account their strengths, needs and risk. Weekly activity planner are not comprehensive. 27/02/2009 4 24 16 The home must complete all the repair, replacement and redecoration work of the individual and communal areas on schedule. 27/02/2009 Care Homes for Adults (18-65 years) Page 28 of 30 Repair, replacement and redecoration work needs completion. 5 24 13 The home must review all the recommendations from the fire risk assessment and conclude implementation on schedule. All recommendations from fire risk assessment to be implemented. 6 34 19 The home must make available all the appropriate evidence with regard to recruitment checks of bank staff. Recruitment checks records for bank staff need to evidence. 27/02/2009 27/02/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 4 5 The home should produce the statement of purpose in a pictorial format. The home should complete signing the terms and conditions for each individual service user detailing the service provision, rights and responsibilities and fees as well. The home should obtain medication consent from the service users or their representative as appropriate. The home should separate current working documents from the old documents and file or archive them as appropriate. 3 4 20 41 Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!